Smart PDF Form

NEW STUDENT WAIVER
Date:*

MonthDayYear
Date
Name*

First NameLast Name
Address:*
Date of Birth:*

MonthDayYear
Date
Phone #:*
Format: (000) 000-0000.
Email:*
example@example.com
How did you hear about me?*
Emergency Contact (name & phone):*
Is there anything the teacher should know? (Medical, injuries, surgeries, etc.):*
Waiver of Liability and Disclosure Form
1. I understand there is an inherent risk associated with any exercise program, including voluntary participation in yoga, which may result in injury. The exercises related to yoga will challenge my cardio, respiratory and musculoskeletal systems associated with: the aerobic, anaerobic, strength, power, flexibility, and breathing components of the program. I understand and am aware that the components of exercise/yoga are potentially hazardous activities and may cause injury.
First and last initial - I have read and understand the above statement*
2. I acknowledge that I have either had a physical examination and/or have been given permission from my physician to participate in a yoga based exercise program, or that I have decided to participate voluntarily without the approval of my physician and do hereby assume all responsibility for my participation in any exercise/yoga activity associated with Moving With Mikayla LLC and Mikayla Lansing.
First and last initial - I have read and understand the above statement*
3. I certify that I am physically well and suffering from no medical problems, conditions, impairments, diseases or illnesses that would prevent my participation or increase the risk of injury and/or illness as a result of partaking in any exercise/yoga program.
First and last initial - I have read and understand the above statement*
4. I, my heirs, or legal representatives do hereby waive and release Moving With Mik LLC and Mikayla Lansing from any and all liability and responsibility from injury, accident, illness, legal and medical fees sustained now or in the future resulting from my participation in any activity or use of equipment.
First and last initial - I have read and understand the above statement*
5. I understand that Moving With Mik LLC and Mikayla Lansing may provide an area for personal belongings to be held during class, however, I agree that Moving With Mik LLC and Mikayla Lansing is in no way responsible for the loss or damage of my belongings while I attend class.
First and last initial - I have read and understand the above statement*